Great Comfort Ministries Pastoral Counseling & Care Center • 501(c)(3) Public Charity • Confidential • Richmond, TX

“In an abundance of counselors there is safety” — Proverbs 11:14

First Consultation Intake Form

A Sanctuary for Healing, Wisdom & Restoration…

Welcome to the Pastoral Counseling & Care Center. Please complete this confidential initial intake to assist our pastoral leadership in understanding your season of life, specific needs, and consultation goals.

1 Confidential Client Information

First Name *

Last Name *

Date of Birth *

Mobile Phone *

Email Address *

City & State *

Marital / Relationship Status *

2 Session Format & Scheduling Preferences

Preferred Consultation Format *

💻 Online Video (Zoom) 📞 Phone Consultation ⛪ In-Person (Richmond Hub)

Preferred Meeting Window

Will a Spouse or Partner Attend?

3 Care Track & Intake Assessment

Primary Care Discipline / Focus Area *

Brief Summary of Current Situation *

Your responses are held in strict pastoral confidentiality.

What breakthrough or outcome are you hoping for?

4 Spiritual Background & Emergency Contact

Current Church Home / Affiliation

Church membership is never required to receive care.

Prior Counseling History

Emergency Contact Name & Relationship *

Emergency Contact Phone *

5 Pastoral Scope & Confidentiality Agreement

I have read, understood, and accept the Ecclesiastical Disclosure, Confidentiality Policy, and Scope of Pastoral Counseling. *

Upon submission, a member of our Pastoral Care Team will review your intake and contact you to confirm your scheduled appointment slot.

First Consultation Intake Form

Ecclesiastical Disclosure & Counseling Scope: